The Gates Foundation's evolving strategy on MNCH Discovery & Tools

At one point, seven teams across the Bill & Melinda Gates Foundation were responsible for research and development investments related to the health of mothers, newborns, and children. In 2018, those teams were aggregated into a single portfolio called the Maternal, Newborn, Child Health Discovery & Tools Portfolio. Over time, the program has shifted focus toward addressing the underlying drivers of maternal and newborn mortality, while its sister team, the MNCH program strategy team, focuses on taking existing innovations and working with partners to tailor them to the contexts where they work. Prior to joining the foundation, Dr. Rasa Izadnegahdar, director of the MNCH Discovery & Tools team, worked in Zambia on pneumonia clinical trials. “The case fatality rate of our participants was 30%, but when you excluded the children who were undernourished, that case fatality rate fell to 0.3%,” he said. “So it was very clear that, if children are dying from pneumonia and diarrheal disease deaths, you could try to meet them at the point of care with the right diagnostic, the right medicine at the right time, in the right sequence of their disease progression. Or you could try to address some of the underlying drivers and have more population-level impact.” Devex spoke with Izadnegahdar about the evolution of the MNCH Discovery & Tools program and their priorities moving forward. “One of our key drivers in creating this team was to bring together the tools and interventions that were impacting MNCH into a single portfolio.” --— Dr. Rasa Izadnegahdar, director of the Maternal, Newborn, Child Health Discovery & Tools, the Bill & Melinda Gates Foundation This conversation has been edited for length and clarity. Can you expand on the reasons for merging the seven teams responsible for MNCH investments into one team? A lot of the child health work that we were doing previously was across the top two killers of children, specifically in the diarrheal disease program as well as in the pneumonia program. But it became obvious that, in order to truly address the residual mortalities given that we had made significant gains on under-5 mortality and maternal mortality, it was really important to shift towards an understanding of where is the residual mortality, and who’s this happening to, and are the innovations that we have still relevant for addressing this more complex residual mortality? Obviously, this was conceived in the pre-COVID era, where these essential health services weren't directly impacted. One of our key drivers in creating this team was to bring together the tools and interventions that were impacting MNCH into a single portfolio. The best example of that is pulse oximetry, which is obviously becoming more important now. On one team, pulse oximetry was being assessed for its value in impacting pneumonia; on a different team, it was being assessed for its value for preeclampsia; and on a separate team, it was being assessed for its in facilities that were overseeing birth. We really felt that by having a single innovation, which has multiple applications across the MNCH space being captured across different teams, you really lose the opportunity to expand use cases when thinking about sort of the MNCH care needs across the system and across the life course. How does a shift toward addressing underlying biological vulnerabilities affect the kinds of investments you make? Devex has covered some of the foundation’s investments in gut health, like the microbiome company behind Evivo, an infant probiotic. How is that connected? I would say there are three foundational principles the team's construct was built on. One was a shift away from specific syndromes to underlying vulnerability. We try to achieve impact as early as possible in the life course to alter the risk trajectory that is setting in very early. So this was a great example of our shift away from stunting programs to actually provide nutrition supplementation to the mom in pregnancy. That shift away from syndromes to underlying vulnerability, and shift to earlier in life so that we could impact the trajectory, were foundational principles and sort of have landed us a little bit more in the maternal health space than we were previously. But even once the baby is born, there's a lot of ways to think about: How do you address the underlying drivers? The important context to remember is we were making this decision at the same time as the foundation was going through an MNCH refresh overall. And so our sister team, the MNCH program strategy team, was at the same time articulating, taking forward more of a focus on existing innovations and existing sort tools that could be bundled. We were doing our best to make sure that, as we shifted to underlying drivers, we weren't saying that investments at the point of care were less relevant, but looking at the data to say where, for example, have we advanced the work so that our team focused on implementation research can actually move those innovations forward? You had 45 research trials looking at different aspects of MNCH care, and nine emerged as ready to advance to more rigorous stages of product development. What were they? The whole 45 is more broad, and I guess I would talk about that in the context of we're interested in innovations that apply to three specific areas. One of them is optimizing maternal health and adverse birth outcomes, so innovations that can be implemented in pregnancy and in labor that improve maternal health and the well-being of the developing fetus. The second area is ensuring that the infant that is born has the best chance of thriving, and that includes developing from a growth perspective, but also from a neurodevelopmental perspective. And then third is at the point of care because hospitalization or care-seeking is in and of itself at risk stratification event. How do we make sure that in the follow-up of the immediate medical interventions, which would be antibiotics or oxygen, that the child is not just being sent back into the community, but that opportunities for interventions that address underlying risk, like nutrition, are captured there as well? In a follow-up email, Dr. Izadnegahdar listed the full nine areas but emphasized that work continues on infant feeding, newborn care devices, drugs targeting abnormal placentation, and more. - Neuroprotection - Lung Surfactant - Antenatal risk stratification suite including AI-enabled ultrasound and point of care diagnostics including hemoglobin - Intrapartum risk stratification suite including AI-enabled wearable sensors - Microbiome-directed ready-to-use therapeutic food - B. infantis probiotic - Balanced Energy Protein maternal nutritional supplementation - IV iron for management of maternal anemia in pregnancy and post-partum - Antenatal corticosteroids